Designing for women healthcare users in Afghanistan
The problem…
85% of Afghan women have experienced physical, sexual, or psychological violence or forced marriage. However, only 20% of ever-married women who have experienced physical or sexual violence have sought help, and less than 1% sought assistance from medical practitioners.
Design challenge: Design and deliver a program to support healthcare facilities and providers to provide trauma-informed, user-centered services for women survivors of domestic and gender-based violence.
My role: Research lead of a team with one field research manager, one public health specialist, and twelve field researchers. I engaged the research stakeholders, developed the research design and tools, led the data collection and data analysis, managed the research team, and prepared research deliverables.
Types of research: Generative, mixed-methods, attitudinal and behavioral research
Design phases: Empathize → Design → Ideate → Prototype
Methods and tools: Field research, Surveys, Observational research, Journey mapping, Interviews, Focus groups, Quantitative and qualitative data cleaning and analysis, Descriptive statistics
To design a solution, the team needed to understand…
what are the experiences and needs of women survivors of domestic and gender-based violence in receiving healthcare services, and what are the needs of healthcare providers and facilities in order to deliver more user-centered services to them? Working with the research stakeholders, we aimed to address the following research questions:
What are the experiences of women survivors of domestic and gender-based violence with healthcare services? What are their needs, motivations, goals, and pain points?
What are healthcare staff members’ experiences providing healthcare services? What do they know, think, believe, and do regarding intimate domestic and gender-based violence?
What are the barriers and opportunities for advancing a trauma-sensitive approach in the public health system in Afghanistan?
So, I developed a research plan…
with a mixed-methods design informed by the 5As framework of quality healthcare. This framework reflects the fit between characteristics and expectations of health service providers and clients in five areas: availability, accessibility, affordability, acceptability and adequacy.
I developed a research plan, workshopped our strategy with project stakeholders, and we translated and pilot tested our tools. We presented our plan, tools, and protocols to the Ministry of Public Health review board and received approval.
We implemented…
our research starting with the facilities and healthcare providers…
Healthcare provider survey
to better understand what they currently knew, thought, and did in providing services in cases of domestic and gender-based violence.
Walk-throughs and observations
I developed a facility checklist and did walk-throughs with staff, observing and assessing the layout, facilities, resources, protocols, and systems in place.
Journey mapping with healthcare providers and facility staff
where we facilitated a “walk-through” current state journey mapping exercise of the current process from the first point of contact with the facility all the way through
discharge and long-term follow-up.
Then, we turned to the patient experience…
Intercept survey and exit interviews with healthcare facility users
I developed a survey and interview protocol for female healthcare facility users. Connectivity and literacy constraints would not allow for recruiting participants or administering the survey remotely, so the research team worked with the facilities to verbally administer the survey with voluntary exit interviews.
Focus groups with shelter residents
Together with the field manager, I facilitated discussions with survivors of intimate partner and gender-based violence who were residing in shelters. The discussion focused on survivors’ decision-making, healthcare seeking behaviors, and experiences receiving healthcare services.
And then we made sure we understood the systems context…
Stakeholder Interviews
with facility directors, the Public Health Directorate and Department of Women’s Affairs, and non-government organizations working in health and provision of services addressing domestic and gender-based violence.
Findings from the exit interviews
Waiting times of facility users
“Patients are all the same to us as doctors, but once we find out a woman has experienced violence, we record it and let the hospital know, but there is not any specific form to record these kinds of cases.”
- Health facility walk-through
“Mostly women don’t tell us about the violence, even it is obviously clear. Some of the women just ignore it. They are not allowed to follow the case by their families, and there are culture barriers.”
- Interview with healthcare provider
“When patients come in, some things are clear from their appearance, and they are not in a good psychological situation. And in some cases, there are signs on their body. We try to provide the patient with an environment where she can trust us. Trust is very important. There are some patients who don’t speak—we should give them some time and the privacy so that they talk about things that they are not initially comfortable talking about."
- Interview with healthcare provider
Attitudes and beliefs of healthcare providers from the survey
We identified the following key research insights…
About healthcare facilities and staff:
Healthcare facility staff had limited knowledge on the prevalence of domestic and intimate partner violence in Afghanistan, physical and emotional consequences, and risk factors.
Healthcare facility staff had limited understanding of re-traumatization and potential harm to a survivor of intimate partner/gender-based violence during an exam.
Healthcare facility staff also had attitudes and beliefs regarding gender-based violence that may affect their ability to provide trauma-sensitive care.
Healthcare providers were not screening for trauma and abuse in the provision of healthcare services.
Healthcare facility staff felt they did not have time to assess or provide referrals and care for intimate partner or gender-based violence, and did not feel it was their place to discuss such issues.
About healthcare users:
Women felt uncomfortable seeking treatment for or even talking directly to a healthcare provider about problems related to gender-based or intimate partner violence.
Very few women sought healthcare services for abuse-related concerns, and even fewer reported the abuse when receiving services.
Some women had received treatment for physical consequences of abuse, but very few had received treatment for the emotional consequences at any point in their life.
Patients felt that the care they received did not adequately address their physical and emotional safety.
Many women would not seek treatment if a female healthcare provider was unavailable.
And as a result of the research…
Based on the learning, the organization developed and delivered: (1) a training of trainers on trauma-sensitive approaches for 100 health professionals working in public healthcare facilities, and a training for 20 hospital managers and the members of the Ministry of Public Health mental health task force.
It was clear from the research that materials from other contexts may not align to user needs, and that the training content needed to be culturally and contextually specific, so the Afghan organization implementing the project developed their own training materials. Based on the research insights, the trainings initially focused on education and challenging attitudes and beliefs that were barriers to trauma-sensitive, user-centered care. Then, the training was designed to give staff practical, light touch tools to screening for abuse and interact with all patients in a way that reduces risk of re-traumatization. Participants were trained on actions to take when a survivor is upset, ways to show a survivor they are interested and care, ways to show a survivor they are listening, and assessing intimate partner and gender-based violence risks.
The training materials advanced approaches that were sensitive to the possibility of offending or scaring women by asking directly about abuse, and were directed largely towards female professionals that women would be most likely to interact with, report to, and receive treatment from more easily. The project also revealed areas where systems-level changes were needed, and this was incorporated into the project. As a result, outcomes included facility policies and protocols for trauma screening and trauma-informed hospital administration and human resources.